Retinal break is the cause of primary retinal detachment, which remains a main cause for visual loss, and closure of the breaks is the principle of treatment. Currently surgical treatment can successfully reattach the retina in most cases. However, some basic questions still beset treatment of the disease, such as the cause responsible for development of retinal breaks and how to prevent it, and how the visual recovery can be satisfactory after reattachment surgery. Recent research indicates that the development of retinal breaks is associated with the process of vitreous liquefaction, posterior vitreous detachment (PVD) and abnormal vitreoretinal adhesion and traction. The retinal breaks can occur in the posterior margin of the vitreous base in the eye with complete PVD. Partial PVD may cause posterior breaks especially in cases of myopic traction maculopathy associated with schisislike thickening in the outer retina (foveoschisis) and vitreomacular traction. It is known that microstructural changes and atrophy of the macula, and epiretinal membrane formation are the reasons for poor vision after the retina is reattached. Therefore, more attention should be paid to further understand the vitreous pathology and traction mechanism, to research for methods of its clinical evaluation and strategy of prevention and treatment, and to accelerate visual recovery after reattachment surgery, in order to raise the standard of the disease treatment.
Objective To investigate the risk factors associated with visual acuity after minimally invasive vitrectomy of idiopathic macular hole (IMH). Methods Forty-six IMH patients (50 eyes) who underwent minimally invasive vitrectomy were enrolled in this prospective clinical study. The patients included eight males (nine eyes) and 38 females (41 eyes), with a mean age of (60.7plusmn;9.6) years. All the patients were examined for Snellen corrected visual acuity (CVA), optometry, slit lamp microscope and preset lens, as well as spectral domain optical coherence tomography (SD-OCT). The CVA was converted into a logarithm of the minimal angle of resolution (logMAR) for statistical analysis. The mean logMAR CVA was 0.95plusmn;0.29 (CVA ranged from 0.02 - 0.6). The mean duration was (11.1plusmn;7.8) months. The mean breaking length of inner segment/outer segment (IS/OS) junction was (1566.9plusmn;830.5) mu;m. The mean maximum diameter of the bottom of macular hole was (914.0plusmn;484.8) mu;m. There were 10, 19, 21 eyes with stage two, three and four IMH, respectively. The therapeutic effects were evaluated at three months after surgery. The relationship between visual acuity after surgery and age, duration, visual acuity before surgery, stage of IMH, breaking length of IS/OS before and after surgery, the maximum diameter of the bottom of macular hole, thickness of photoreceptors after surgery were analyzed. The safety of minimally invasive vitrectomy for IMH was observed. Results Three months after surgery, the closure rate of macular hole was 100.0%. The mean logMAR CVA was 0.45plusmn;0.25. The mean thickness of photoreceptors and breaking length of IS/OS were (183.8plusmn;62.6), (477.5plusmn;341.9) mu;m respectively. The mean breaking length of IS/OS after surgery was significantly shorter than before surgery (t=12.679, P＜0.001). The difference of logMAR CVA before and after surgery was statistically significant (Z=6.571, P＜0.001). The logMAR CVA before surgery (r=0.569), duration (r=0.465), breaking length of IS/OS before (r=0.574) and after surgery (r=0.564) had a positive correlation with logMAR CVA after surgery (P＜0.001). The logMAR CVA after surgery was independent of age, the maximum diameter of the bottom of macular hole and thickness of photoreceptors after surgery (r=0.546, 0.361, -0.441; P＞0.05). The logMAR CVA after surgery in eyes with stage four IMH was significant decreased than that in eyes with stage two and three IMH (Z=0.455, 2.556; P＜0.05). Except 17 eyes with complicated cataract and eight eyes with macular epiretinal membrane, there were no other surgery-related serious complications. The cataract eyes had improved visual acuity after phacoemulsification. Conclusion The visual acuity before surgery, duration and breaking length of IS/OS are main influence factors of visual acuity after surgery.
Objective To compare the outcome of pars plana vitrectomy (PPV) with triamcinolone (TA) assistance and internal limiting membrane (ILM) peeling for the treatment of moderate and extreme highly myopic macular hole retinal detachment (MHRD). Methods Forty-one highly myopic MHRD patients (41 eyes) who underwent PPV with TA assistance and ILM peeling were enrolled in this study. These eyes were divided into two groups according to different anatomic features: group A (24 eyes) had a consistent moderate long axial lengths (＜29 mm), quot;mildquot; retinal pigment epithelium (RPE) and chorioretinal atrophy, and posterior staphyloma (level 0 - 1 and depth le;2 mm); while group B (17 eyes) had a consistent extreme long axial lengths (ge;29 mm), quot;severequot; RPE and chorioretinal atrophy, and posterior staphyloma (level 2 - 3 and depth＞2 mm). All the patients underwent C3F8 tamponade at the end of PPV. The anatomic reattachment of the retina, macular hole closure, and visual acuity were observed at 12 months after surgery. Results The rates of retinal reattachment and macular hole closure were 91.67% and 58.33% in group A, 64.71% and 17.65 % in group B in the first time of surgery. The differences of rates of retinal reattachment (P=0.049) and macular hole closure (chi;2=6.787, P=0.009) between two groups were statistically significant. The rates of retinal reattachment and macular hole closure were 95.83% and 58.33% in group A, 88.23% and 29.53% in group B in the second time of surgery. The difference of retinal reattachment rate between two groups was not statistically significant (P=0.560). The difference of macular hole closure rate between two groups was statistically significant (chi;2=4.894, P=0.027). Twelve months after surgery, the vision acuity improved in 14 eyes, unchanged in nine eyes, and decreased in one eye in group A; the vision acuity improved in six eyes, unchanged in eight eyes, and decreased in three eyes in group B. The differences of vision result between two groups was not statistically significant (chi;2=0.209, P=0.647). Conclusion After PPV with TA assistance and ILM peeling, the rates of retinal reattachment and macular hole closure in eyes with moderate highly myopic MHRD are higher than that in eyes with extreme highly myopic MHRD, but there is no difference in visual acuity.
Objective To compare the outcome of pars plana vitrectomy (PPV) with triamcinolone (TA) assistance and with or without internal limiting membrane (ILM) peeling for retinal reattachment and macular hole closure of moderate highly myopic macular hole retinal detachment (MHRD). Methods Forty-three moderate highly myopic MHRD patients (43 eyes) with proliferative vitroretinopathy in class A or B, moderate long axial lengths (ge;26 mm but ＜29 mm), mild retina pigment epithelium and chorioretinal atrophy, and posterior staphyloma (0 - 1 level and le;2 mm) were enrolled in this study. The patients were divided into two groups according to surgical options: TA-assisted PPV with ILM peeling (group A, 24 eyes), TA-assisted PPV without ILM peeling (group B, 19 eyes). The anatomic reattachment of the retina, macular hole closure, and corrected visual acuity (CVA) were observed at one week, one, three, six and 12 months after surgery. Results Twelve months after surgery, retinal reattachment was achieved in 22 eyes (91.67%) and 18 eyes (94.74%) in group A and B, respectively. The difference of retinal reattachment rate between two groups was not statistically significant (Fisherprime;s exact test, P=1.000). Macular hole closure was in 14 eyes (58.33%) and 11 eyes (57.89%) in group A and B, respectively. The difference of macular hole closure rate between two groups was not statistically significant (chi;2=0.049，P=0.824). The differences of CVA between two groups was not statistically significant (chi;2=0.001, P=0.977). Conclusion ILM peeling may not be necessary in the surgery of TA-assisted PPV for moderate highly myopic MHRD.
Objective To observe the effect of pars plana vitrectomy (PPV) with epiretinal membrane peeling (ERMP) and (or) internal limiting membrane peeling (ILMP) and silicone oil tamponade for highly myopic macular hole retinal detachment (MHRD) with posterior staphyloma. Methods Eighty-five highly myopic MHRD patients (85 eyes) were enrolled in this study. All the patients were examined for corrected visual acuity (CVA), slit lamp microscope and preset lens, indirect ophthalmoscope, A/B ultrasound, optical coherence tomography (OCT) and intraocular pressure examination. The average axial length was (29.1plusmn;1.8) mm. There were 24 eyes with diffuse choroid atrophy and 61 eyes with partial choroid atrophy. The CVA was converted into a logarithm of the minimal angle of resolution (logMAR) for statistical analysis. The average logMAR CVA was 1.93plusmn;0.37. All the patients were treated with PPV and triamcinolone acetonide or indocyanine green (ICG) assisted ILMP and (or) ERMP and silicone oil tamponade. TA assisted ERMP was performed in 21 eyes; with ICG assisted ILMP in 56 eyes and TA assisted ILMP in eight eyes. The duration of silicone oil tamponade was (6.2plusmn;1.6) months. CVA, retina and macular hole status and complications were observed postoperatively. Differences between preoperative and postoperative CVA were evaluated by the t test and correlation analysis. Multiple logistic regression analysis was performed to assess the influence of individual preoperative factors on the initial anatomical success. Differences in the macular hole closure rate between eyes with or without macular schisis were evaluated for statistical significance using corrected chi-square. Results The mean logMAR CVA was 1.34plusmn;0.48 after surgery, which significantly improved compared to that before surgery (t=39.38, P＜0.01). The CVA after surgery was independent of axial length (r=0.142, P＞0.05), choroid atrophy (t=0.23, -0.165,P＞0.05) and macular hole closure (t=0.12, -0.005, P＞0.05). The retina reattached in 79 eyes (92.9%) and recurrence of retinal detachment occurred in six eyes (7.1%). Multiple logistic regression analysis indicated that recurrence of retinal detachment was independent of choroid detachment, proliferative vitroretinopathy, axial length, choroid atrophy and ILMP (OR=1.428, 5.039, 0.815, 2.578, 0.432; P＞0.05). Of these 85 eyes, macular hole closed in ten eyes (11.8%), macular hole did not close in 75 eyes (88.2%). There were 24 eyes (28.2%) experienced high intraocular pressure during the first 2 weeks after surgery, all of them were under control with drugs. There were 12 eyes (14.1%) presented with high intraocular pressure before the silicone oil removal, all of them were under control only by silicone oil removal. Conclusion For the treatment of MHRD with posterior staphyloma, PPV combined with ERMP and (or) ILMP and silicone oil tamponade show a high retinal reattachment rate.